Dennis Drotar

Meta-Analysis of Psychological Interventions to Promote Adherence to Treatment in Pediatric Chronic Health Conditions

OBJECTIVE To estimate the effectiveness of adherence-promoting psychological interventions for pediatric populations with chronic health conditions. METHODS A meta-analysis was conducted on 70 adherence-promoting psychological intervention studies among chronically ill youth using a weighted least squares approach and random effect model. RESULTS Medium effects sizes were found for the behavioral (mean d =.54, 95% confidence interval [CI] = 0.34-0.73, n = 10) and multi-component interventions (mean d =.51, 95% CI = 0.45-0.57, n = 46), while educational interventions displayed a small effect size with adherence (mean d =.16, 95% CI = 0.10-0.22, n = 23). Study designs incorporating pre-post comparisons yielded effect sizes approaching the medium range (mean d =.42, 95% CI = 0.36-0.48, n = 30). CONCLUSIONS Behavioral and multi-component interventions appear to be relatively potent in promoting adherence among chronically ill youth. Recommendations for future research and methodological issues are presented.

Association Between Adherence and Glycemic Control in Pediatric Type 1 Diabetes: A Meta-analysis

CONTEXT: Although adherence has been identified in practice guidelines for youth with type 1 diabetes to promote optimal glycemic control, there has been no systematic integration of studies investigating the adherence-glycemic control link. This recommendation partly stemmed from the Diabetes Control and Complications Trial (DCCT); however, this trial did not comprehensively measure adherence and had only 195 adolescents. OBJECTIVE: Our goal was to determine the magnitude of the adherence-glycemic control link in pediatric type 1 diabetes and evaluate its correlates. METHODS: Our data sources were PubMed (1950–2008), Scopus (1950–2008), and references from reviews in pediatric type 1 diabetes. Studies that included youth under age 19 with type 1 diabetes and a reported association between adherence and glycemic control were eligible for inclusion. Articles were not included if they contained youth with type 2 diabetes, had study samples that overlapped with other studies, or the results came from intervention studies. Of the eligible 26 studies, 21 had sufficient statistical data. Two authors independently extracted information by using a standardized protocol. Agreement between coders was high. RESULTS: The mean effect size across 21 studies, including 2492 youth with type 1 diabetes, was −0.28 (95% confidence interval: −0.32 to −0.24). As adherence increases, A1c values decrease. No sample or disease characteristics were correlates of the adherence-glycemic control link. Pre-DCCT studies had a mean effect size of −0.32 (8 studies; 1169 participants) compared with −0.25 in post-DCCT studies (13 studies; 1323 participants). CONCLUSIONS: This meta-analysis supports the adherence-glycemic control link in pediatric type 1 diabetes. The weaker post-DCCT association suggests that the approach to intensive diabetes management has shortcomings. We conclude that this is because of a mismatch between what scientists and clinicians know is the best way to manage pediatric type 1 diabetes and the capabilities of youth and their families.

Behavioral Outcomes of Extremely Low Birth Weight Children at Age 8 Years

Objective: To describe the prevalence of behavioral problems and symptomatology suggestive of Autism and Aspergers disorders at age 8 years among extremely low birth weight (ELBW, <1 kg) children, born 1992 through 1995. Method: Parent reports of the behavior of 219 ELBW (mean birth weight, 810 g; gestational age 26 weeks) were compared with 176 normal birth weight children of similar maternal sociodemographic status, sex, and age. Behavior was assessed via the Child Symptom Inventory that includes both Symptom Severity Scores and scores meeting DSM-IV criteria for disorders. Results: ELBW compared with normal birth weight children had significantly higher mean Symptom Severity Scores for the inattentive, hyperactive, and combined types of attention-deficit hyperactivity disorder (all p < .001) as well as higher scores for Generalized Anxiety (p < .01) and Autistic (p < .001) and Aspergers (p < .01) disorders. When DSM-IV criteria were considered, ELBW children also had significantly higher rates of attention-deficit hyperactivity disorder of the inattentive (10% vs 3%, p < .01) and combined (5% vs 0.6%, p < .05) types. Conclusions: Attention-deficit hyperactivity disorder, mainly the inattentive type is prevalent among ELBW children. Our findings of an increase in symptoms pertaining to Autistic and Aspergers disorders at school age agree with recent reports of others during early childhood. Early identification and intervention for these problems might improve child functioning and ameliorate parent and child distress.

Pediatric Self-management: A Framework for Research, Practice, and Policy

Self-management of chronic pediatric conditions is a formidable challenge for patients, families, and clinicians, with research demonstrating a high prevalence of poor self-management and nonadherence across pediatric conditions. Nevertheless, effective self-management is necessary to maximize treatment efficacy and clinical outcomes and to reduce unnecessary health care utilization and costs. However, this complex behavior is poorly understood as a result of insufficient definitions, reliance on condition-specific and/or adult models of self-management, failure to consider the multitude of factors that influence patient self-management behavior, and lack of synthesis of research, clinical practice, and policy implications. To address this need, we present a comprehensive conceptual model of pediatric self-management that articulates the individual, family, community, and health care system level influences that impact self-management behavior through cognitive, emotional, and social processes. This model further describes the relationship among self-management, adherence, and outcomes at both the patient and system level. Implications for research, clinical practice, and health care policy concerning pediatric chronic care are emphasized with a particular focus on modifiable influences, evidence-based targets for intervention, and the role of clinicians in the provision of self-management support. We anticipate that this unified conceptual approach will equip stakeholders in pediatric health care to (1) develop evidence-based interventions to improve self-management, (2) design programs aimed at preventing the development of poor self-management behaviors, and (3) inform health care policy that will ultimately improve the health and psychosocial outcomes of children with chronic conditions.

A meta-analysis of the neuropsychological sequelae of chemotherapy-only treatment for pediatric acute lymphoblastic leukemia

Mixed findings on the neuropsychological sequelae of chemotherapy‐only treatment for pediatric acute lymphoblastic leukemia (ALL), without radiation, indicate the need for a comprehensive meta‐analytic review. The purpose of the current study was to conduct a meta‐analysis assessing neuropsychological and academic functioning differences between children with ALL treated solely with chemotherapy and comparison groups.

A prospective study of long-term caregiver and family adaptation following brain injury in children.

Objective:We examined long-term differences in family adaptation following traumatic brain injuries (TBI) and orthopedic injuries. Design:Families of children with severe TBI (n = 53), moderate TBI (n = 56), and orthopedic injuries (n = 80) were assessed at baseline, 6 months, and 12 months post injury and at an extended follow-up an average of 4.1 years post injury. Caregiver and family outcomes were examined using mixed model analysis. Results:Patterns of adaptation over time varied across groups but indicated long-standing injury-related stress and burden in the severe TBI group. Conclusions:Severe TBI results in persistent caregiver stress for a substantial proportion of families.

Executive Functioning, Treatment Adherence, and Glycemic Control in Children With Type 1 Diabetes

OBJECTIVE The primary aim of the study was to investigate the relationship among executive functioning, diabetes treatment adherence, and glycemic control. RESEARCH DESIGN AND METHODS Two hundred and thirty-five children with type 1 diabetes and their primary caregivers were administered the Diabetes Self-Management Profile to assess treatment adherence. Executive functioning was measured using the Behavior Rating Inventory of Executive Functioning and glycemic control was based on A1C. RESULTS Structural equation modeling indicated that a model in which treatment adherence mediated the relationship between executive functioning and glycemic control best fit the data. All paths were significant at P < 0.01. CONCLUSIONS These results indicate that executive functioning skills (e.g., planning, problem-solving, organization, and working memory) were related to adherence, which was related to diabetes control. Executive functioning may be helpful to assess in ongoing clinical management of type 1 diabetes.

Cognitive functioning in children on dialysis and post‐transplantation

Abstract: We studied 124 children, 62 patient‐subjects who had end‐stage renal disease (ESRD) and 62 sibling‐controls who closely matched the patient‐subjects in terms of their ethnicity and their socioeconomic status, to discern whether children with ESRD would perform less well than their siblings on standardized achievement and intelligence quotient (IQ) tests, and to determine whether ethnicity would influence such results. The subjects were recruited from nine pediatric transplant and dialysis centers across the United States. Thirty‐one subjects were white (Euro‐American), 17 were African‐American, and 14 were categorized as ‘other’. The average age of the patient‐subjects was 13.7 ± 0.44 yr; and of the sibling‐controls 13.7 ± 0.38 yr. Most patients (61%) and siblings (84%) were in regular school classes, and most (87% and 92%, respectively) attended school full‐time. The average IQ percentile rank for the patients was significantly lower than their siblings (31 ± 4 vs. 44 ± 5, respectively, with normal = 50). Patients tended to score lower on achievement tests compared with their siblings (spelling: 88.7 ± 4 vs. 94.6 ± 2; arithmetic: 88.5 ± 2 vs. 94.0 ± 2; reading: 91.9 ± 2 vs. 100 ± 3, respectively). Patients scores on achievement tests were influenced by age at diagnosis and by the mother/caregivers lower achievement. Also, increased time on dialysis predicted lower scores on achievement tests. Neither dialysis/transplant status nor ethnicity significantly affected outcome. Our data suggest that ESRD, but not ethnicity or dialysis/transplant status, is a risk factor for lower IQ and academic achievement, especially in younger children, in children who spend more time living with ESRD, and in children whose mothers/caregivers have lower educational levels.

Influences on adherence to pediatric asthma treatment: a review of correlates and predictors.

Nonadherence to treatment is an important influence on the health outcomes of children and adolescents with pediatric asthma, which is the most prevalent childhood chronic illness. Because the factors that influence treatment adherence for pediatric asthma are not well understood, a comprehensive review of relevant research is needed. To address this need, research concerning the correlates and predictors of adherence to inhaled corticosteroid treatment for pediatric asthma was reviewed. Significant predictors and correlates of treatment adherence identified in this review were consistent with a conceptual model that included family demographic characteristics and functioning, parent and child characteristics, health care system and provider characteristics, and child health outcomes. Family functioning and parental beliefs about asthma and medication treatment demonstrated consistent relationships with treatment adherence. Future research should test multivariate models of influences on treatment adherence in pediatric asthma in prospective studies using reliable and valid measures of predictors and outcomes. Intervention studies are also needed that target potentially modifiable, empirically supported influences to enhance treatment adherence. The clinical management of pediatric asthma would be enhanced by routine assessment of barriers to treatment adherence and anticipatory interventions that address them to prevent nonadherence.

Depressive Symptoms and Glycemic Control in Adolescents With Type 1 Diabetes: Mediational role of blood glucose monitoring

OBJECTIVE To determine whether the association between depressive symptoms and glycemic control is mediated by blood glucose monitoring (BGM). RESEARCH DESIGN AND METHODS A total of 276 adolescents with type 1 diabetes (mean age ± SD, 15.6 ± 1.4 years) completed a measure of depressive symptoms. Sociodemographic and family characteristics were obtained from caregivers. BGM frequency and glycemic control were obtained at a clinic visit. RESULTS Separate regression analyses revealed that depressive symptoms were associated with lower BGM frequency (B = −0.03; P = 0.04) and higher A1C (B = 0.03; P = 0.05) and that lower BGM frequency was associated with higher A1C (B = −0.39; P < 0.001). With depressive symptoms and BGM frequency included together, only BGM frequency was associated with A1C and depressive symptoms became nonsignificant (B = 0.02; P = 0.19). The Sobel test was significant (Z = 1.96; P < 0.05) and showed that 38% of the depression-A1C link can be explained by BGM. CONCLUSIONS BGM is a mediator between depressive symptoms and glycemic control in adolescents with type 1 diabetes.